VBAC Concluding Statement (part 5) A Better Way ~ Opportunities to improve the situations

A Better Way ~ opportunities to improve the maternity care & the VBAC situation in California:

What society needs is a rational system for providing ‘mother-baby-father-friendly’ maternity care, one that functions logically for childbearing families by meeting their practical as well as biological needs. The goal is nothing less than affordable, accessible, women-centered, mother-baby friendly maternity care with seamless access to comprehensive obstetrical services as medically indicated or as requested by the childbearing woman.

Logically this would also require it to be a cost-effective form of healthcare that protects, promotes and preserves the health of already healthy women during normal pregnancy, childbirth, postpartum-neonatal period as well as and new mother-new baby developmental phase of breastfeeding and newborn care.

But the lived reality of our current obstetrically-centric, defensive medicine system for maternity care system is neither rational nor logical. Statistics for mother-baby outcomes have never shown the medicalization of normal childbirth to provide superiors outcomes or more cost-effective care for healthy childbearing women with normal pregnancies.

And yet the surgical speciality of obstetrics and gynecology has systematically, over the course of the last century, completely taken over the care of essentially healthy women and turned that highly medicalized model into the standard of care for all maternity care in the US.

What is both surprising and disturbing is that no one at a policy level has asked the obvious question:

  • Does it make sense to turn healthy women with normal pregnancies into the patients of a surgical speciality and normal childbirth into a surgical procedure ‘performed’ by an obstetrically-trains surgeon
    The critical missing element for maternity care in the US is systematically providing physiologically-based maternity care to the majority of the childbearing population (70-plus percent).

An equally important and unexamined is the affect of society’s uncritical acceptance of this unscientific premise over the entire 20th century and well into the 21st. For the last half of the 20th century and first decades of the 21st, obstetrics has been a surgical specialty beleaguered by the need to practice defensive medicine, as efforts to reduce medical malpractice litigation became the central organizing principle of modern obstetrics. The uncritical acceptance of the irrational notion that obstetrical surgeons should be the primary provider for normal childbirth in healthy women has had an increasingly pernicious effect on childbearing women over this 40 year span of time.

Obstetricians and nurse-midwives are required to follow the medicalized protocols of hospitals trying to protect themselves against litigation, as well as trying to keep costs down. Under such conditions it is no surprise that obstetrical care is not longer focused on mothers and babies (the original meaning of ‘maternity’ care), and instead has turned inward and is mainly focused on the needs of the obstetrical profession.

If that were not the case, the considerable influence of the obstetrical profession would have been used to both eliminate VBAC bans and to promote normal vaginal birth whenever and wherever possible, while working to remove economic roadblocks instead of occasionally cluck their tongues over the ‘VBAC problem’, while quietly accepting of the self-serving behavior of hospitals and medical malpractice carriers that have instituted bans on VBACs.

Solutions to the VBAC Problem: Hospital-based physiological childbirth as provided by midwives and other professional birth attendants

If the obstetrical profession is actually committed to reducing the number of Cesarean performed in the US (the very best answer to the ‘VBAC problem’), they will need to support the physiological management of normal childbirth for what it is — the science-based standard of care for healthy women with normal pregnancies.

That is best accomplished by:

  • New legislation to create standard informed consent for obstetrical procedures by providing full, accurate, factual, and scientifically-validated information about the known risks and benefits associated with the routine intrapartum use of the following: immobilization in bed during active stages of labor, continuous EFM, IVs, induction or augmentation of labor with drugs that speed-up labor, AROM, IUPC, narcotics pain medications, epidural analgesia during labor, standard forms of anesthesia used during normal childbirth, episiotomy, forceps, vacuum extraction, and the specific risks of primary as compared to repeat Cesarean surgery.
  • Comprehensive informed consent would enable childbearing women and their families to provide fully and accurately-informed consent before these interventions and procedures are used during labor or birth, thus reducing the risk of subsequent malpractice suits and other kinds of legal action against providers and hospitals.
  • Adding the principles of physiological management for normal labor and birth to the standard medical school curriculum
  • Teaching the skills and techniques that support physiologic childbirth during the training of obstetrical residents
  • Insisting that ACOG include physiologically management as a recognized aspect of the scope of practice for obstetricians OR that hospital L&D units be staffed by professional midwives who will manage labors and births physiologically unless obstetrical interventions are medically indicated
  • Facilitating hospital privileges for all California professional midwives (including midwives licensed by the California Medical Board)
  • Insisting that all hospitals eliminate VBAC bans and that medical malpractice carriers not be able to financially discriminate (by fee hikes or refusing liability coverage) against the provision of VBAC by obstetricians
  • Acknowledge that a tiny minority of previous Cesarean women will, with fully informed consent, still choose to midwifery care in an OOH setting

Most women who previously had a Cesarean would not choose OOH midwifery care if they had access to in-hospital midwifery management. For the few mothers who had such a traumatic experience that, as they put it, they: ” just can’t return to scene of the crime” can, with good informed consent, be satisfactorily cared for in a OOH setting by professional midwives.

So far as I know, the obstetrical profession in general, and ACOG as its active spokesmen, are neither promoting nor supporting these vitally important solutions. Until they do so voluntarily, or legislation is passed mandating these actions, we will continue to have an irrational, illogical, unproductively expensive, and ultimately unethical maternity care system that is the product of a special interests and decidedly not “mother-baby-father-family friendly”.

The concluding words to CCM’s VBAC statement comes from a Canadian government report dated June 30, 2008 on improving maternity care called “Maternity Matters” : (reference at bottom)

California licensed midwives, childbearing families and consumers agree and since we couldn’t have said it better, so we won’t try.


PDF download for this document
Maternity Matters ~ Choice, Access, Continuity and Safe Service
Canada 2008

We know a great deal about what is needed. With so much evidence about what works, why is it still not in place? Fewer medical students see uncomplicated births and fewer are choosing to do obstetrics and maternity care in their practice.

There is most certainly a media focus on the drama of alarming birth stories: the baby who was saved, the extraordinary delivery, the life-saving medical interventions, and not nearly enough about uncomplicated, straightforward supported births – to be equally celebrated.

There is a wealth of evidence about what women need and want before implementing new policies. Good maternity care starts with an understanding that pregnancy and birth are ordinarily healthy events, with a belief that most of the time the mother and baby will continue to develop together as they have for millennia.

We already know how to make sure that pregnancy, birth and beyond are healthy and safe for both women and babies. We know that when the mother’s basic needs are met, with safe housing, nutritious food, aseptic technique, as well as attentive individualized care, most women will have a healthy pregnancy.

Mothers and babies thrive when women can give birth close to home or in their own home, when birth is allowed to unfold without interference and women feel safe, confident, well cared for by birth attendants, when babies and mothers are attended in the early weeks after the birth, encouraged through the physical and emotional changes, assisted in breastfeeding and watched for signs of normal development.

Excellent maternity care should not be about a specific provider, location or procedure, but rather about a philosophy and model of care that is woman- and family-centred. Many providers could, in fact, offer woman- and family-centred care if supported by appropriate changes in the definition, funding and delivery of maternity care services.

It should be grounded in the recognition that birth is a normal healthy process, based on the available evidence. It should be sustainable, close to home, publicly funded, one-to-one care. Maternity care must be available as needed during pregnancy, through labour and in the critical early weeks after the birth.

For these factors to be in place, we need political will and interest to see maternity care as a vital part of primary care.

We need policy makers to invest in education of midwives. We need nursing and medical training to include many opportunities to be part of straightforward births.

The current approaches to maternity care tend to put budgets and efficiencies ahead of the needs of women and families.

We need to reform our thinking as well as our approach to maternity care if we hope to provide the best possible care and support for women and their families as they make their way from pregnancy to parenting.

Maternity Matters highlights the Government commitment to developing a high quality, safe and accessible maternity service through the introduction of a new national choice guarantee for women. This will ensure that by the end of 2009, all women will have choice around the type of care that they receive, together with improved access to services and continuity of midwifery care and support.